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Monday, March 30, 2009

Immigrant and Refugee Health

The New York Times (March 29, 2008) has a front-page story about the challenges faced by clinics caring for large numbers of immigrants and refugees.[1] It focuses on the International Clinics at Hennepin County Medical Center in Minneapolis, MN, and particularly emphasizes issues confronting Somali refugees and their caregivers.

Many of these issues, including language and cultural difficulties, and the problems of poverty that often afflict people in these groups, are not new to the United States. Our multi-cultural, multi-ethnic (and sometimes “melting pot”) society has long tradition of immigrants arriving from other countries and cultures and presenting “new” challenges to the social service and health care systems. Each group of new arrivals has been seen as “different”, and many that were previously seen as outsiders, such as Jews, Italians, and Irish, have become insiders[2][3],[4][5] One obvious exception has been African-Americans, whose ancestors were brought here as slaves, and who have never (unlike the ethnic groups in the books referenced above, have never “become white”; indeed, that very term derives from the special place of oppression that has been reserved for black people in this country.

One point not really addressed by the Times article is the difference between immigrants and refugees. While the US has had both over its history, immigrants have always been the dominant group. Refugees came after WW II, and after the Vietnam war, and after every war. Immigrants are searching for a better life for their families, and despite the hardships, they have chosen to make the change. They are, historically and currently, different people from those who stay, more willing to take risks, more buoyed by hope. Refugees, on the other hand, are fleeing often horrific situations; they are not coming by choice but by lack of choice. Life in their homeland is intolerable. Thus, while both groups may hold onto their cultural values, beliefs and habits, for refugees this may be all that they have.

The Times notes that, largely in response to pressures from Somali refugees who will not allow themselves to be delivered by male physicians, the obstetrics staff at Hennepin County has become almost entirely female. This decision has been made, de facto or de jure, but many other issues also exist that are not as easy to resolve? When does respect for the culture of someone else (a good thing, generally) become limited by the implications? Providing interpreters is good but very expensive; providing female obstetricians and midwives is probably good, and may be part of an overall transition in obstetrics. But what about “female circumcision”, genital mutilation, also common among Somali women? If this is a core “cultural” tradition, highly desired by a refugee (or immigrant) group, does this mean it should be provided? I think not. A similar example (though not specific to Somalis, let me be clear): If a woman is battered by her partner and this is explained as “part of their culture”, would this make it any more ok? Again, I think not, but these examples illustrate the continuum of decisions that have to be made in delivering health care to refugee and immigrant (as well as “native”) people.

Refugees are also much more likely than immigrants to have experienced terrible personal tragedy; the deaths of friends and family members, often in violent and gruesome ways, rape, mutilation. Post-traumatic stress disorder (PTSD) is common. On the “plus” side, once having been granted refugee status, they are legal in the US, and eligible for certain benefits. Many of our immigrants are “illegal”; they do not have papers and are increasingly denied access, as the Times article points out, except in certain “safety net” venues, or until they come in to the emergency room very ill. Our increasingly restrictive laws see limiting access to health care as both a way of saving money (“why should we pay for these illegals?”) as well as being a punishment.

Which, as it often does on these pages, brings us back to money. Why does Hennepin County Medical Center bear the burden of this care? Why are there not other medical centers and doctors throughout the Minneapolis area taking equal responsibility for poor and uninsured immigrants and refugees? Why is this also a problem in every other major city, including my town of Kansas City and my state of Kansas, in which there are no publically funded hospitals? Everyone wants the best of care for themselves and their families, but the definition of “best” is very open to question (not only for cultural, but for medical reasons as well, as I have often discussed). In addition, the costs may become untenable. There is only so long that honorable people can say “Do for me (and mine); save the money on you (and yours).” Eventually we need a comprehensive and rational care system, which deliveries necessary care to all before there are frills for any.